New HAES Study

Science is not a sacred cow. Science is a horse. Don’t worship it. Feed it.
— Aubrey Eben

The new Health At Every Size paper, by Linda Bacon and Lucy Aphramor, is titled Weight Science: Evaluating the Evidence for a Paradigm Shift.   From the abstract:

Current guidelines recommend that “overweight” and “obese” individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. […] A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. […]  This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.

If it isn’t clear, this isn’t reporting new research: it’s reviewing and tying together existing research on HAES, and discussing why HAES is preferable than the traditional weight loss advice.   The introduction explains the basics of Health at Every Size and the research supporting it.

Several clinical trials comparing HAES to conventional obesity treatment have been conducted. Some investigations were conducted before the name “Health at Every Size” came into common usage; these earlier studies typically used the terms “non-diet” or “intuitive eating” and included an explicit focus on size acceptance (as opposed to weight loss or weight maintenance). […] [Only randomized controlled trials (RTCs) and] studies with an explicit focus on size acceptance were included.

Evidence from these six RCTs indicates that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, eating disorder pathology) and psychosocial outcomes (e.g, mood, self-esteem, body image) […] (See Table 1.) All studies indicate significant improvements in psychological and behavioral outcomes; improvements in self-esteem and eating behaviors were particularly noteworthy […]. Four studies additionally measured metabolic risk factors and three of these studies indicated significant improvement in at least some of these parameters, including blood pressure and blood lipids […]. No studies found adverse changes in any variables.

Clicking the “Table 1” link goes to a summary of studies from 1998 to 2009.   Many of us are familiar with “Bacon et al, 2005 and 2007“, which refers to the study Linda Bacon, Judith Stern, Nancy Keim and Marta Van Loan conducted to compare a standard diet program with a HAES program and its follow-up report.  It’s discussed in detail in Linda Bacon’s book Health At Every Size: The Surprising Truth About Your Weight and in a few articles.  The other studies primarily vary in what types of outcomes they measured.

The next major section details the assumptions people make about the weight-loss paradigm.  Each of these assumptions is discussed, with an eye to showing the actual evidence (or lack thereof). For example:

Assumption: The only way for overweight and obese people to improve health is to lose weight
Evidence: That weight loss will improve health over the long-term for obese people is, in fact, an untested hypothesis. One reason the hypothesis is untested is because no methods have proven to reduce weight long-term for a significant number of people. Also, while normal weight people have lower disease incidence than obese individuals, it is unknown if weight loss in individuals already obese reduces disease risk to the same level as that observed in those who were never obese […].
As indicated by research conducted by one of the authors and many other investigators, most health indicators can be improved through changing health behaviors, regardless of whether weight is lost […]. For example, lifestyle changes can reduce blood pressure, largely or completely independent of changes in body weight […]. The same can be said for blood lipids […]. Improvements in insulin sensitivity and blood lipids as a result of aerobic exercise training have been documented even in individuals who gained body fat during the intervention […].

This is followed by a discussion of the support for using a HAES approach instead of a weigh-loss approach; the components of HAES (body acceptance, intuitive eating, and being active); and the ethics of using a HAES approach vs a weight-loss approach.  Naturally, being an academic paper, there’s an abstract, appendix, disclosures of conflicts of interest, etc.

Overall, the discussion I’ve seen of this paper seems to reflect people’s expectations.  The paper isn’t about HAES per se, it’s about how HAES is a better approach to improving health in fat people than prescribing weight loss (assuming, of course, that health improvements are desired).   The value of the paper for me is that it:

  • Summarizes the current state of HAES evidence, with bibliography. There isn’t just one study that supports HAES — multiple researchers have had similar results.
  • Argues the case for HAES in an organized fashion.
  • The full text of the paper is freely available on the web. You don’t have to get it from the library.
  • It helps show the current holes in the research.  There isn’t a randomized controlled trial comparing a diet approach vs a HAES approach in men, for example.  Most studies did not track physiological measures (e.g. blood pressure, blood lipids) in dieters vs the HAES participants.

The ethics discussion is also interesting.  Many doctors who are asked in the media about “If diets don’t work, what do you tell patients?” tend to come back with “Well, keep trying” or weight-loss surgery (as if that’s not a diet).   Linda Bacon and Lucy Aphramor argue outright that “the HAES paradigm shift may be required for professional ethical accountability.”

Further reading:

Also: NYTimes blog post on HAES and this paper.

Surgeon General: Dance for Fun

From a recent New York Times interview with the US Surgeon General, Dr Regina Benjamin:

My thought is that people should be healthy and be fit at whatever size they are.
[…]
I want exercise to be fun; don’t want it to be work. I don’t want it to be so routine that you’re bored with it. We used to jump rope a lot and double Dutch and went to a disco to have fun and enjoy ourselves. We didn’t go to the disco because somebody said, Go dance for 30 minutes. […] I want us to get back to doing things because they’re fun.

She also gave up some of her MacArthur Award payments to take the job as Surgeon General.

A few links

Marilyn Wann launched a new HAES site at  http://2011revolutions.blogspot.com/, focusing at replacing diet resolutions with a revolution.

Jezebel: If You’re Fat-Phobic, You’re Also An Ignorant, Bigoted Idiot and Biggest Weight Stories of 2010.

“I don’t eat a hamburger and large chips every day!” A qualitative study of the impact of public health messages about obesity on obese adults. From the abstract:

Personal and contextual factors influenced the ways in which individuals interpreted and applied public health messages, including their own health and wellbeing and perceptions of stigma. […] Many described feeling stigmatised and blamed by the simplicity of messages and the lack of realistic solutions. Participants described the need [for] messages recognise the complexity of obesity and focus on encouraging healthy behaviours for individuals of all sizes.

You may recognize co-author Dr Samantha Thomas, who blogs at Discourse.

 

Today on Twitter: Body Acceptance

I don’t plan to write a lot of posts about things I say on Twitter, because I figure if you want to read it you’ll read it on Twitter.

But I have a couple today I’d like to share to a wider audience.

Today, Polimicks (of http://www.polimicks.com/ and http://polimicks.livejournal.com) decided to tweet about body acceptance, using a “#bodyacceptance” tag (which in twitter searches for things with that tag).  Some of the things she tweeted were:

Polimicks#bodyacceptance Don’t know if this tag exists, but it does now. I have some griping to do about diet culture today.

Polimicks#bodyacceptance Diet policing in general, and I know it’s mostly subconscious for a lot of folks.

Polimicks#bodyacceptance The constant, almost subconscious body and diet policing we all do. “Should she be wearing THAT?” So hard to stop.

Polimicks#bodyacceptance Oh, and if you’re only polite to people you find fuckable, you’re an asshole.

I decided to join in.

Living400lbs Why do yet another weight loss resolution? http://www.bellaonline.com/articles/art11830.asp #bodyacceptance

Living400lbs #bodyacceptance RT @JeromeGlassman My “resolution” for the year is to continue practicing #HAES and to try to be kind to my body and myself!

Living400lbs #bodyacceptance RT @HarrietBrown 5 New Year’s resolutions actually worth making: http://bit.ly/hoRIIx

Living400lbs You only have one body. Why is making peace with it a radical act? #bodyacceptance

So…thought y’all might like the sentiments (or links) and those of you on twitter might want to join the party ;)

Things I Would Like To Not Care About

I would like to not worry about:

  • Whether a medical professional will consider my symptoms before making a diagnosis.
  • Whether a job interviewer will not hire me because I’m fat.
  • Whether the friend talking about her diet is doing so as a way of passive-aggressively commenting on my body size, eating habits, or perceived dieting status.
  • Whether I will be seen as an equal partner in my friendships and family relationships, or seen as “stuck” with whoever will have me.
  • Whether a bathroom stall will be wide enough for me bend over and wipe everything, or if I’ll end up squatting “sideways” in the stall.
  • Whether the person who keeps looking at me while I eat is actually engaging in voyeurism without my consent.

I’d like…

  • I’d like my breathing hard walking uphill to be seen as a function of exertion, not fatness.
  • I’d like my periodic wheezing to be seen as a symptom of asthma, not fatness.
  • I’d like the fact that I’m married to not be a shocker.
  • I’d like the fact that I have sex to not be a shocker.
  • I’d like people to treat my exercising as about function and pleasure, not as “a major life choice deserving of applause” OR about weight loss OR as a reason to shout insults at me.
  • I’d like my food choices to be about nourishing my body, about helping my body function well, and about pleasure — not about weight OR being a “bad fatty” OR being a “good fatty”.

I sometimes joke about having “dieting PTSD” from my teenage years, but really, a lot of these buttons were installed by my family (which is not at all uncommon).   I am trying to decouple weight from food and exercise.  I’m trying to decouple health from weight.  I’m not perfect, but I’m working on it.  Most of the time hearing other people talk about diets isn’t a problem, per se — it may be uninteresting, but doesn’t always and automatically start a round of self-recriminations or a visit from The Ghost of Failed Diets Past, and I consider that a win.

I also realize that some of these buttons — like someone commenting on my food choices — are going to get pressed, simply by living in this society, so I’m trying to “disconnect” them.  (This would be easier if there were an actual wire leading from the “button” to my brain that I could reroute or disconnect!)  Again, I’m not always successful, but I’m working on it.

Some of these, like how employers perceive fat applicants or how medical professionals’ biases harm fat patients, do affect my life in very real ways.  I can advocate for myself, I can overdress to seem “more professional than thou”, but all I can do is the best I can.

What about you?  Does this strike a chord for you, or not?

Thankful Thursday

[a not-always-weekly exercise in gratitude]

The man of the house baked a chicken with some rosemary this evening.  He accompanied it with broccoli with cheese sauce,  green beans steamed with red potatoes, corn cooked with onions, cold sliced beets, and French bread.   As we were eating he said, “So did I make the Thankful Thursday this week?”

So. Um. Today I’m thankful for:

  1. The man of the house (and not just for cooking dinner!)
  2. The guest room TV is now connected to the VCR for using ancient aerobics tapes, and we cleaned, dusted, and vacuumed in there over the weekend so it doesn’t irritate my allergies to be in there.
  3. This positive article on Health At Every Size.
  4. Having my asthma under better control.  I’m not only breathing (and feeling!)  better, I’m also getting sick a lot less.  I think some of those cold/flu “things” I would perennially have were asthma/allergies (and/or the asthma made me more susceptible to having them).
  5. New Alexander James Adams album to preorder.  :)

This isn’t all that’s going on this week by any means.  I just find it helpful to focus on the positive sometimes.

QOTD: Exercise

From Linda Bacon, in an interview at Psych Central:

[E]xercising regularly will have a much more dramatic improvement on the health of a fat person than if he or she were to lose weight. Thin people don’t have longer life spans solely based on their weight. Fitness levels play a much larger role in health than weight. Put a focus on activities that you enjoy and just be open-minded around weight. The exercise itself has a dramatic effect on your health.

Another HAES Quote

This quote on Health At Every Size is from Michelle, aka The Fat Nutritionist.  Links within the quote were added by me.

[D]ieting purports to make all people lose weight, permanently. Because 80-95% of the people who engage in it do not lose weight permanently, dieting fails as an intervention. It fails to achieve its stated directive, and it also doesn’t seem to help people permanently pick up healthier eating/moving behaviours.

Whereas HAES does not purport to do *anything* to a person’s weight. It purports to encourage healthier eating and moving. And while only a few people might lose weight, just like in dieting, HAES succeeds as an intervention — because the goal was to engage in healthier behaviours, not to lose weight, in the first place. Evidence has shown (in Linda Bacon’s study) that HAES does actually succeed in getting people to adopt healthier eating and moving behaviours that stick around for the long-term.

I realize that this is not always an either-or.  But for many fat people, it’s assumed that either you are actively trying to lose weight through eating “better” or eating less or exercising more … and the weight not coming off, or not staying off, is then a reason to quit the healthy behaviors.

Thanks Frances at Corpulent for linking to Michelle’s post on Health At Every Size.

Fat Acceptance Quote for Parents and Teachers

If you exercise as “punishment” for weighing too much, how can you learn to enjoy being active? If you eat salads only as a way to change the body you hate, how will you enjoy the wonderful tastes of fresh vegetables?

Besides, if hating one’s body effectively motivated change, do you really think there would be many heavy people in the world?

Accepting yourself as you are today doesn’t mean giving up. It means learning to live in the present with the body you have. It means facing and acknowledging reality.

— Linda Bacon, PhD, in Health at Every Size: The Surprising Truth about Your Weight.

Expectations (and Risks) of Weight Loss

Lots of folks have been quoting the new paper in the International Journal of Obesity

Weight loss of 15% or more from maximum body weight is associated with increased risk of death from all causes among overweight men and among women regardless of maximum BMI.

“Associate”, here, appears to mean “correlate”.   The 15% piqued my interest because it echoed this bit* from The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, from the US National Institutes of Health (NIH) guidelines on “obesity treatment”:

Obese individuals typically want to lose 2 to 3 times the 8 to 15 percent often observed and are disappointed when they do not.  (p32)**

Correlation does not necessarily mean causation, but this leads me to wonder whether, on average, a more than 15% loss requires more extensive changes to diet and exercise, that in turn can result in more muscle loss and other damage?    Nobody knows.  It’s not clear whether the correlation is a strong one (3000% more likely?) or a weak one (100% more likely?) or if it will actually mean anything in the end.   But I do think we should focus more on health than on weight.

I also note they did find one group where weight loss reduced risk of cardiovascular disease:  obese men who lost between 5% and 15% of their max weight.  I also note that reducing risk of cardiovascular disease can be done by increasing exercise and other such changes, without focusing on weight loss.


*Posted about here.

**For convenience, I’m using PDF page numbers, which can be entered into the PDF viewer to go directly to the page in question.  These do not map to the printed page numbering.

Quote of the Day

From an Alternet article focusing on Linda Bacon’s book Health At Every Size, Jamie Oliver’s new show, and Michelle Obama’s “Let’s Move” campaign:

[R]esearch shows that people of all sizes have similar diets, but it only manifests as weight gain in some of us. People today eat more calorie-dense, nutrient-poor convenience foods than Americans did in the past. How we eat also plays a role, as eating while focusing on something else like driving, or eating while in a stressful situation affects our digestive processes. As the average American diet has gone downhill for people of all sizes, weight gain occurred for some — contributing to the high rate of obesity in America today — but Bacon says that “assuming fat people are eating worse than thin people is wrong.” For this reason, focusing efforts on obesity sends the message to thin people that they do not need to make any changes in their lifestyles when in fact they may also engage in unhealthy behaviors that put them at risk for disease.

Second, focusing on obesity stigmatizes larger people and imbues everyone with a fear of fat. Instead of encouraging people to adopt healthy behaviors, an anti-obesity message encourages the development of eating disorders and the adoption of dangerous, restrictive eating habits. In fact, dieters readily admit they are willing to engage in unhealthy eating patterns in order to lose weight. Bacon encourages focusing on health instead of weight and promoting acceptance of people of all body shapes and sizes. […]

The AP article that declared Huntington, West Virginia the fattest and unhealthiest town in America also says the town’s economy “has withered.” The piece describes a high poverty rate and an unemployment problem teamed with the problem of low-paying jobs with poor benefits for those who have work. In fact, when the mayor was confronted about his city’s health problems, he replied that he was too busy worrying about the economy to think about public health. The best way to accomplish Michelle Obama and Jamie Oliver’s goals is to address social injustice and to reduce poverty in America. Why aren’t either of them talking about that?

The article also mentions that a second edition of Health At Every Size has been released.  (I reviewed the first edition here.)

Freedom to Cook

Dieting taught me to appreciate machinery-measured and packaged food with detailed nutritional labels.   Why?

It made the math easier.

I didn’t have to weigh things.  I didn’t have to dig out a ruler or measuring spoons.  Calories, carbs, protein — it’s all there, neatly printed, and totally uniform.  Sure, I had a few recipes memorized:

  • An omelet with 1 slice of cheese and 1 slice of ham chopped up.
  • Two Ritz crackers with 1 tablespoon of peanut butter.
  • A sandwich with 3 slices of ham, 3 of turkey, 2 slices of cheese, 1 tablespoon mustard and 2 slices of whole-wheat bread.

I used them over and over, too.   I ended up in quite the food rut, because it was easy.

What got me thinking about this?  Making breakfast Saturday morning.  Instead of “what recipe to follow” I poked around the fridge.  I scrambled eggs, diced red pepper, diced onion, bacon bits, green onion slices, and cheese together to go with toast and jam and coffee.  I ended up comparing this to my last few diets and how nice is was to be able to just cook whatever I thought would be tasty and not be limited by carbs or fats or what-have-you.

Am I eating more food?  Very likely, since I’m not trying to limit carbs or calories.  But I’m also eating more varied food and arguably healthier food.

Quote of the Day: Fat Acceptance Made Exercise Easier

One of the things I like exploding people’s heads with is the fact that embracing FA made it *easier* for me to exercise. Before, exercise was always this horrible, dreary thing I “had” to do so that I’d be “thin,” and if I didn’t get “thin” I was failing, which made me not want to exercise. Once I accepted fat as okay, exercise became a lot more enjoyable, because it’s something I do to feel better and find enjoyment in movement and how my body works, rather than an obligation I dread. I can enjoy exercise on its own terms now, and that makes me more likely to do it.

Icprncs, in response to this fab rant on FA

What would you put into a Fitness for Life class?

Everyone’s talking about Lincoln college requiring students with a BMI of 30 or larger to take a “Fitness for Life” class.

What I’m wondering is, what would you like to see in such a class?  Not what is usually in such classes, or what Lincoln is including — what would rock your socks to see?

Here’s some ideas:

Topics:

Reading list:

Activities:

  • Critiquing popular fitness articles & ads
  • Weightlifting and bodyweight strength training
  • Dancing, walking, and other “stealth” aerobics
  • Stretching and Yoga

What do you think?  What would you add?  I’d like to put in a weight-neutral “how to exercise” book but I’m not sure one exists…